Palliative and Hospice Care
Health care professionals are generally not as comfortable dealing with issues related to death and dying as they are with supporting the patient through curative treatment. Knowledge and skill in providing physical and emotional comfort to dying patients and their families is essential to providing optimum care to persons with advanced, progressive diseases. Palliative care is a relatively new specialty that focuses on promoting the best possible quality of life for patients facing serious life-threatening illness through optimal management of physical, psychosocial, emotional, and spiritual symptoms. This specialty grew out of the hospice movement and is continuing to evolve as more palliative care teams are integrated into health care systems, more palliative care content is taught in schools of medicine and nursing, and more research is conducted to support an evidence base for palliative interventions.
Palliative care is both a philosophy of care and an organized, highly structured system for delivering care. The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies (National Consensus Project for Quality Palliative Care [NCPQPC], 2004). Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for the patient and family, optimizing function, helping with decision making, and providing opportunities for personal growth. It can be delivered concurrently with life-prolonging care or as the main focus of care.
Palliative care can and should be initiated at the diagnosis of a serious life-threatening or chronic, progressive illness and continued throughout the course of the illness across all care settings. As illustrated in the figure on page 438, palliative care is started along with life-prolonging therapies at the initial diagnosis of a life-threatening illness. As the disease progresses, there is a greater and greater emphasis on palliative interventions versus life-prolonging interventions. Hospice care is the part of the palliative care continuum when the emphasis is no longer on life prolongation, but primarily on comfort. In the United States, this is often defined as the last 6 months of life and is based on the eligibility requirements for hospice benefits under Medicare.
The NCPQPC defines palliative care as “medical care provided by an interdisciplinary team…focused on the relief of suffering and support for the best possible quality of life for patients facing serious life-threatening illness, and their families. It aims to identify and address the physical, psychological, spiritual, and practical burdens of illness” (NCPQPC, 2004). Palliative care is distinguished from routine symptom management by the following:
Every patient diagnosed with cancer needs good symptom management from the time of diagnosis. Patients whose cancer is diagnosed at an advanced stage or whose cancer progresses during or after treatment are likely to have multiple physical, psychological, emotional, or spiritual concerns. The expertise of the palliative interdisciplinary team can be especially helpful at this time.
• Persons with multiple symptoms or those with one or more symptoms that are difficult to manage. Common symptoms include pain, dyspnea, nausea, vomiting, anorexia, constipation, fatigue, anxiety, and confusion.
Palliative care services are most effective when integrated into the care setting. Various models are used to facilitate access to the expertise of the palliative care team. These models include one or a combination of some of the following:
The figure on page 438 illustrates that hospice care is the part of the palliative care continuum when life-prolonging therapies are no longer providing benefit. The focus of care is on comfort and quality of living by affirming life and viewing dying as a normal process. Services provided by the hospice interdisciplinary team include pain and symptom management, psychosocial and spiritual support, assistance and support with direct caregiving, and bereavement care for both the patient and family. The practice guidelines outlined by the NCPQPC (see box on right) also apply to the organized, comprehensive services available through hospice programs.
Palliative care’s place in the course of illness. From National Consensus Project for Quality Palliative Care. (2004). Clinical practice guidelines for quality palliative care. Retrieved February 5, 2007, from http://www.nationalconsensusproject.org.